Comprehensive Management Strategies for Diabetes

Team-Based Care Approach

The American Diabetes Association recommends that diabetes care should be managed by a multidisciplinary team including physicians, nurses, dietitians, exercise specialists, pharmacists, dentists, podiatrists, and mental health professionals 2, 1
Care should align with the Chronic Care Model to ensure productive interactions between a prepared proactive practice team and an informed activated patient 3
Treatment decisions should be timely, evidence-based, and tailored to individual patient preferences, prognoses, and comorbidities 3

A complete medical evaluation should classify diabetes type, detect complications, review previous treatment, and establish a management plan 1
Laboratory tests should include blood glucose tests, lipid profile, kidney function tests, and urine tests 1
Screen for autoimmune conditions in type 1 diabetes, such as thyroid dysfunction and celiac disease 1
Assess for comorbidities including obesity, hypertension, dyslipidemia, and existing microvascular complications 1

Set individualized blood glucose targets based on patient's age, comorbidities, risk of hypoglycemia, and life expectancy 1
Regular blood glucose testing (typically every 3-6 months) is recommended to assess long-term glycemic control 1

Implement medical nutrition therapy with individualized meal planning 1
No ideal percentage of calories from carbohydrate, protein, and fat exists for all people with diabetes; macronutrient distribution should be based on individualized assessment 1
Various eating patterns can be effective, including Mediterranean-style, DASH, plant-based, lower-fat, and lower-carbohydrate patterns 1
Focus on weight loss (if indicated) by reducing intake of saturated fat, trans fat, and cholesterol while increasing intake of ω-3 fatty acids, viscous fiber, and plant stanols or sterols 4

Encourage at least 150 minutes of moderate-intensity aerobic activity per week, reduced sedentary time, and resistance training at least twice weekly 5, 1

For overweight/obese patients, prescribe high-intensity diet, physical activity, and behavioral therapy designed to achieve ≥5% weight loss 1
Recommend 500-750 kcal/day energy deficit to promote weight loss 1

Most patients with type 1 diabetes should be treated with multiple-dose insulin injections or continuous subcutaneous insulin injection 5
Patients should use insulin analogues to reduce hypoglycemia risk 5
Patients should be educated on matching prandial insulin doses to carbohydrate intake, preprandial blood glucose levels, and anticipated activity level 5

Initiate pharmacologic therapy at diagnosis of type 2 diabetes, in addition to lifestyle therapy 1
Metformin is the preferred initial pharmacologic agent if renal function is adequate 5, 1
When monotherapy with a noninsulin agent at maximum tolerated dose does not achieve or maintain the blood glucose target over 3 months, a second agent should be added 5
Consider patient factors when selecting medications, including efficacy, cost, potential side effects, weight effects, comorbidities, and risk for hypoglycemia 5

Patients with diabetes and hypertension should have a blood pressure treatment goal of less than 140/90 mm Hg 4
Lifestyle therapy should consist of weight loss, reduced-sodium diet, moderate alcohol intake, and increased physical activity 4
Pharmacologic therapy should include either an ACE inhibitor or ARB (but not both) 4

Statin use is recommended for most persons with diabetes aged 40 years or older 4
Lifestyle modification should be recommended to improve the lipid profile 4
In addition to intensive lifestyle therapy, statin intensity should be based on the patient's risk profile 4

Hypoglycemia may be reversed with administration of rapid-acting glucose (15-20g) 5
Patients should be educated on situations that increase their risk for hypoglycemia, such as fasting for tests or procedures, during or after exercise, and during sleep 5

Provide DSMES to all patients at diagnosis and at critical points throughout their care 1
Education should focus on helping patients make informed self-management choices rather than simply providing information 1
Include essential content on hypoglycemia/hyperglycemia recognition and treatment, medication administration, blood glucose monitoring, and nutritional management 1
A patient-centered communication style that incorporates patient preferences, assesses literacy and numeracy, and addresses cultural barriers to care should be used 3

Conduct regular screening for microvascular complications, including annual comprehensive eye examination, screening for diabetic kidney disease, and comprehensive foot examination 1
Screen for and treat modifiable cardiovascular risk factors 1
Provide all age-appropriate vaccinations 1